PrEP provision in healthcare settings: UK and France Dr Michael Brady Kings College Hospital Terrence Higgins Trust London
Content How to integrate PrEP provision into: Sexual health services General health services How do we develop services that best engage with those who are not currently accessing PrEP? What might future models of care for PrEP look like? Developed with input from colleagues in Scotland, Wales and France as well as from personal experience
PrEP in the United Kingdom England Impact Trial 10,000 places Scotland PrEP approved on NHS (generic drug) Wales PrEP project on the NHS Northern Ireland No PrEP programme
PrEP in France PrEP available since January 2016 Initially delivered through HIV clinics Wider roll-out to sexual health services in 2017 Initially Truvada and now generic TDF/FTC Approx 7,000 people on PrEP
Uptake of PrEP in France N = 5,352 Reference
Characteristics of PrEP users: France
Characteristics of PrEP users: France
Characteristics of PrEP users: France
Characteristics of PrEP users: France
Awareness and PrEP knowledge PrEP campaigns
Engagement Third sector support essential for engagement and awareness raising, media work, legal, policy and political work and informing PrEP provision The work of individuals and community organisations will continue to play a key role in defining future service models
PrEP provision: Sexual Healthcare Existing network of sexual health services facilitates scale up Complex issues have became more apparent after roll out Engaging with non-msm is a challenge Different service models exist Services have found it efficient to channel into dedicated PrEP clinics Consultation times longer The complex MSM consultation Initial restriction to hospital HIV specialists limited scale up Typical 4 6 week wait for PrEP initiation appointment Sexual Health clinics funded to provide PrEP from end of 2017
PrEP provision: Sexual Healthcare PROS Better knowledge of PrEP than other healthcare areas May already have existing PrEP support services Many MSM at higher HIV risk are already attending CONS There are many who are not attending sexual health services and for whom these services are not accessible or acceptable There are practical implications which limit access Consultation time Capacity Workforce In some settings funding could be a restriction
Wider healthcare: primary care In the UK there is no PrEP provision in general practice settings Awareness of PrEP is relatively low amongst primary care physicians Sexual Health and HIV prevention is patchy in primary care Commissioning and drug reimbursement processes do not support primary care involvement We are developing approaches with GPs to include PrEP assessment and monitoring forms in their electronic clinical records (EMIS) Greater involvement and engagement with primary care and other healthcare settings may support PrEP use in those who don t access sexual health services
Funding PrEP is cost effective and potentially cost saving Drug price Targeted at those most at risk Devolved governments of Scotland and Wales fund PrEP In England funding for PrEP services is split between NHS England (drugs) and local councils (services) Healthcare funding models, limited resources and restrictions on where PrEP can be offered are a concern
Integrating PrEP into existing healthcare (1) Ensure equity of: Knowledge and awareness Engagement Access Uptake Engage with community organisations working with those at greater HIV risk Migrant communities Black and Minority Ethnic (MSM and non-msm) Heterosexuals who may be at increased risk Trans communities
Integrating PrEP into existing healthcare (2) Sexual health services Wider workforce involvement in PrEP support and provision Capacity issues and funding will need to be addressed We need new ways to ensure sexual health services are acceptable and accessible for all Community based services may address some of these issues
Integrating PrEP into existing healthcare (3) Wider healthcare primary care (GP) Increase knowledge and skill of other healthcare workers Some, if not all, of the PrEP pathway should be delivered outside of sexual health services Working with primary care and IT providers to integrate PrEP into clinical consultations Campaigns directed at GPs re: PrEP
Integrating PrEP into existing healthcare (4) Supporting self-management PrEP is already self-managed Online access to drug is well established Online and digital STI and HIV testing services are increasingly becoming the norm We should utilise technologies already being used and developed for PrEP provision Some, or all, of the PrEP pathway could be delivered on-line which may be: More acceptable? More accessible? Less costly?
PrEP@Home: Assessing the feasibility of a home care system Aaron J Siegler, PhD Department of Epidemiology Rollins School of Public Health Emory University Atlanta, GA, USA Siegler et al. International AIDS Conference Durban, South Africa July 18-22 2016
Integrating PrEP into existing healthcare (4) Online PrEP provision HIV and STI prevention information Risk assessment PrEP information to support decision to start PrEP and dosing HIV and STI testing and renal monitoring PrEP initiation and on-going prescribing Wrap-around support services Mental health Drug and alcohol Chemsex Interactive and online
Research and evaluation C i ica Alternative dosing strategies for non-msm Monitoring e.g. renal, bone health, Hepatitis C E gageme t How do we engage with those not accessing PrEP What should the proportion of women, trans men and women, cis heterosexuals be? Service mode s What, where and by whom? Scotland - funded study to better understand the impact on clinics of implementing a PrEP programme
Acknowledgments Dr Rak Nandwani Consultant, Sexual Health and HIV Greater Glasgow and Clyde Professor Jean-Michel Molina Professor of Infectious Diseases University of Paris Diderot Professor Claudia Estcourt Glasgow Caledonian University Dr Nicola Steedman Consultant in Public Health Edinburgh Dr Olwen Williams Consultant, Sexual Health and HIV Betsi Cadwaladr University Health Board, North Wales President, BASHH Dr Jade Ghosn Hôpital Hôtel Dieu Paris Greg Owen I Want PrEP Now Terrence Higgins Trust